Insurance status impacts complication rates after shoulder replacement surgery

The findings, which appear in the Journal of Shoulder and Elbow Surgery, demonstrate disparities in acute postoperative outcomes for shoulder replacement surgery based on insurance status.

Shoulder replacements (arthroplasties) are recommended for patients suffering from various conditions, including shoulder arthritis, irreparable rotator cuff tears and fractures. The primary goal of the procedure is pain relief, with a secondary benefit of restoring motion, strength, function and returning patients to an activity level as near to normal as possible.

Using a large, national administrative database (The Healthcare Cost and Utilization Project Nationwide Inpatient Sample), the researchers analyzed more than 100,000 cases (68,578 Medicare; 27,159 private insurance; 3,544 Medicaid/uninsured and 4,009 other) of patients undergoing shoulder arthroplasty (partial or hemi, total, and reverse) procedures. Overall, the perioperative medical and surgical complication rate was 17.2 percent and the mortality rate was 0.20 percent. However, they found that there was a significantly higher rate of medical, surgical and overall complications among Medicare (20.3 percent) and Medicaid/uninsured (16.9 percent) patients compared with privately insured (10.5 percent) patients. When the data was matched and analyzed, the researchers found no differences in the complication rates between Medicaid/uninsured and Medicare patients. However, both the Medicaid/Uninsured and Medicare patients had significantly more medical and surgical complications when compared to the privately insured patients.

According to the researchers, this discrepancy in the complication rates may be the result of a lack of access to both preoperative and postoperative care due to poor socioeconomic status or education level for patients that have government sponsored insurance. Additionally, patients with Medicaid or no insurance may lack access to high volume shoulder surgeons, which may also contribute to the higher complication rates. The authors also found that patients with private insurance are likely to go to higher volume hospitals to have their elective shoulder replacement surgery done.

"Studies in the literature have shown that patients with Medicaid or no insurance have a higher mortality rate after penetrating trauma compared to private insured patients. Patients with Medicaid also have higher medical complication rates after spine surgery. We report similar findings that patients with government-sponsored insurance are more likely to have medical and surgical complications compared to privately insured patients after shoulder replacement surgery. Thus, insurance status should be considered an independent risk factor for medical and surgical complications in patients undergoing shoulder replacement surgery." said corresponding and first author Xinning Li, MD, assistant professor of orthopaedic surgery at Boston University School of Medicine.

Li believes future research should focus on both clinical and socioeconomic factors to determine the reason for possible differences in the postoperative complications and outcomes in patients after shoulder replacement surgery between government sponsored and private insurance.

"Understanding that disparities in patient care exist is an important first step. Patients with no insurance or Medicaid/Medicare insurance do not have the same access to care compared to someone with private insurance. The next logical question to ask is why these disparities exist, and subsequently, what can be done to eliminate its occurrence to improve patient care while minimizing postoperative complication," added Li, an orthopedic surgeon that specializes in sports medicine and shoulder reconstructive surgery at Boston Medical Center.